Documentation Dissection

Pre and Postoperative diagnosis: Uncontrolled moderate open angle glaucoma, left eye |1|.

Procedure: Trabeculectomy of externo with peripheral iridectomy |2|

Anesthesia: Conscious sedation, peribulbar block.

Estimated blood loss: Less than 1 cc.

COMPLICATIONS: None.

The patient has had progressive visual field deterioration on maximum tolerated medications, and pressures in the high teens with a diagnosis of uncontrolled open angle glaucoma, left eye. To preserve her visual field, it was felt that surgery was necessarygiven the extensive damage to her optic nerve and field already existing |3|. The risks, benefits, and alternatives to surgery were discussed with the patient as well as with her husband, and she was anxious to proceed.

PROCEDURE: The patient was brought to the operating room where she was given an intravenous sedative and peribulbar block. She was then prepped and draped in customary sterile fashion for intraocular surgery. A wire lid speculum was placed, and a 6-0 Vicryl traction suture was put through the superior peripheral cornea. The globe was retracted downward.The conjunctiva was entered 12 mm proximal to the limbus. With a combination of blunt and sharp dissection it was dissected down to the surgical limbus. The Gill’s knife was used to bare the limbus, and hemostasis was achieved with bipolar cautery |4|. A 4 x 4 mm rectangular lamellar flap was outlined with the 200 to 300 micron blade, |5| after which Mitomycin C 0.3 mg/cc was applied to the surface of the sclera overlying the outlying trap door for 2 minutes 30 seconds.

The sponge and all instruments used to manipulate the Micomycin sponge were removed from the field, and the eye was vigorously irrigated with balanced salt solution (BSS).

A paracentesis was then made at the 3 o’clock position, and Healon injected into the anterior chamber. The lamellar flap was then dissected into peripheral clear cornea, the anterior chamber entered with a 75 blade, and a posterior lip sclerectomy performed with the Kelly-Descemet punch |6|. A superior peripheral iridectomy was already present, but was enlarged to avoid entrapment |7|. The rectangular flap was then closed using five 10-0 monofilament sutures, and the knots were rotated and buried. The conjunctiva was closed using a running, interrupted 8-0 Vicryl suture. Atropine 1% was applied to the eye several times, after which Tobradex ointment and monocular dressing were placed on the eye.

The patient tolerated the procedure well and was taken to phase II in excellent condition with instructions for a follow up visit at noon on the day after surgery. 0800 was preferred, but the patient indicated that transportation was not available.

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|1| Diagnosis to report.

|2| Indication of the procedure that will be performed.

|3| Indicates the moderate stage glaucoma.

|4| Creation of a conjunctival pouch.

|5| Scleral flap is created.

|6| The anterior chamber was entered and part of the sclera was removed.

|7| This patient had a previous iridectomy, it was enlarged during this operation.

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1 What are the CPT® and ICD-10-CM codes reported?

CPT® Code: 66170-LT

ICD-10-CM Code: H40.10x2

Rationale: CPT®: In the CPT® Index look for Trabeculectomy ab Externo. Two options are listed; in Absence of Previous Surgery or with Scarring Previous Surgery. While there is mention that this patient had a previous iridectomy, no scarring is described. Report 66170 with modifier LT indicating the surgery was performed on the left eye. A separate code is not reported for the iridectomy because the two options listed under Iridectomy/for Glaucoma are indicated in the code description as a separate procedure meaning these codes can only be reported if no related procedure was performed during the same operative session. The iridectomy is bundled in code 66170 and not reported separately.

ICD-10-CM: In the Alphabetic Index, look for Glaucoma/open angle referring you to subcategory code H40.10-. Turn to the Tabular List to complete the code. There are no codes to describe laterality, however a seventh character for the glaucoma stage is required. Documentation shows the stage is moderate, so the 7th character is reported as 2. Add placeholder “x” in the sixth character position and report code H40.10x2.